Provider Demographics
NPI:1316037138
Name:REED S WILSON MD A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:REED S WILSON MD A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REED
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-753-7311
Mailing Address - Street 1:325 N MAPLE DR UNIT 10417
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90213-4919
Mailing Address - Country:US
Mailing Address - Phone:310-753-7311
Mailing Address - Fax:
Practice Address - Street 1:435 N ROXBURY DR
Practice Address - Street 2:SUITE #300
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-5027
Practice Address - Country:US
Practice Address - Phone:310-859-9170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45920207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG45920Medicare ID - Type Unspecified